Overstretched. Under-resourced.

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1 RCN LABOUR MAR KET REVIEW Overstretched. Under-resourced. The UK nursing labour market review 2012

2 Authors James Buchan Ian Seccombe Queen Margaret University Acknowledgements The authors acknowledge the support of the Royal College of Nursing (RCN) UK, in preparing this report. They also wish to note the contribution of the Nursing and Midwifery Council (NMC) who provided unpublished data. The authors alone are responsible for the contents of the report. Executive Summary The 2012 Labour market review (LMR) of the UK nursing labour market highlights the impact of financial pressures on the current and future NHS nursing workforce. It shows that cost containment is contributing to reductions in the numbers of commissioned training and education places, to reductions in staff numbers, pay freezes and reduced training budgets for the nursing workforce. The report shows that all of these factors have an obvious impact on the size, shape and sustainability of the workforce, which in turn have implications for patient care. While there was growth in the NHS nursing workforce across most of the last decade, there are now increasing indicators of overall staffing decline, driven by reduced funding for intakes to training and much diminished levels of international recruitment. Workforce scenarios in NHS England strongly point to the likelihood of reduced supply of NHS nurses over the next five to 10 years. Just as the NHS appears to be facing increasing problems with the supply of nurses, workforce planning is also being confronted by different challenges including ongoing and significant gaps in nursing workforce data. In England, these shortcomings in data are compounded by uncertainty regarding the future of workforce planning structures. The report gives an overview of the new organisations which are intended to take over workforce planning in England, but goes on to explain that the new system is not yet fully defined or implemented, and is approximately a year behind schedule. The LMR looks at staffing numbers and up to date figures are not available for the whole of the UK, data for the NHS in England shows a reduction in nurse staffing of around 5,780 (headcount) and 3,700 (whole time equivalent) between May 2010 and June As well as a decline in the stock of current nurses, the major supply sources of new nurses to the NHS pre-registration nurse education in the UK and international recruitment have both been in decline. In the last decade, international recruitment made a major contribution to workforce numbers, yet this flow has slowed considerably due to a series of policy changes, including tougher NMC requirements and changes to the immigration system. The international contribution to the annual inflow to the NMC 1

3 register peaked at half of all new annual registrants in 2002 and now represents around 18 per cent. In the international context, the UK has moved from a situation of net inflow of nurses to a position of net outflow in recent years, meaning that more nurses are moving abroad than are coming to the UK to practice. The main destinations are Australia, Canada, New Zealand and the USA. The LMR looks at data for pre-registration education. In the early part of the last decade, pre-registration education, funded by UK government had seen investment in increasing numbers. This has now been reversed, with a year-on-year reduction to numbers across all UK countries. The declining level of funded training places is much lower than the supply of applications to enter pre-registration nurse education and is therefore a direct consequence of funding decisions. Experience from the 1990s shows that cutting student numbers led to a year-on-year reduction of new entrants from 18,980 in 1990/91 to 12,000 in 1997/98, which was a major factor contributing to an acknowledged nursing shortage later in the decade. This report highlights that there is a risk of repeating this funding and planning. In 2011/12 there were approximately 22,640 places across the UK, compared to 24,800 in 2010/11. Next year, there will another 1,260 fewer places with a total of around 23,380. This report also looks at trends in the use of bank and agency nursing staff and notes that it is virtually impossible to reach conclusions about its scale or scope, due mostly to the fragmented nature of data. There is also very little evidence on the impact of quality and continuity of care related to the use of temporary nursing staff. This lack of clarity around numbers and lack of transparency on the reasons for using temporary staff point to the need for improved evidence and data in order to better inform policy and planning. The LMR ends with an overview of the different systems of workforce planning in place across the four UK countries. It looks in most detail at England where radical restructuring is taking place, including a stated move to an employer-led approach. It warns of the risks involved in this approach, which was last attempted in the 1990s and led to an undersupply in the nursing workforce. It warns that cost containment pressures often lead to local employers taking a narrow, local view of their future requirements, without taking sufficient account of changed demand and of labour market dynamics and staff flows. As these narrow views are aggregated up to regional and national level, the end result can be a significant underestimate of future requirements for nursing staff. As a new system of workforce planning emerges slowly in England, all four UK countries face the same challenges of funding pressures, increased demand as well as an ageing nursing workforce. Against this background, the LMR concludes that across the UK there is a growing risk of insecurity of future nurse supply. 2

4 Background This report is the 2012 annual review of the UK nursing labour market commissioned by the Royal College of Nursing (RCN). In the twelve months since the last Labour Market Review (LMR) was published, the post-recession impact on the NHS workforce has become clearer, and for the first time since the annual LMR began publication in 2001 we report on an actual decline in NHS nurse staffing numbers across the four UK countries. Moreover, associated indicators suggest that the decline is likely to become a deepening trend unless remedial policy action is initiated. Any assessment of the NHS nursing workforce must start from a position of acknowledging that NHS funding levels are a major determinant both of the current profile, and likely future shape of the profession. The NHS is the sole provider of funds for home based education of new nurses to enter the UK nursing labour market, and is the main source of employment for qualified nurses. In addition, government policy plays a major role in facilitating, or blocking, entry to the UK of non-eu nurses. Between 2011/12 and 2014/15 there will be very little growth, if any, in spending on the NHS. In England, the NHS must make up to 20 billion efficiency savings to meet the forecast growth in demand for health services over this period. NHS trusts and NHS foundation trusts face downward pressure on their income with 4 per cent efficiencies built into national tariffs and financial penalties if they do not meet performance standards 1. According to National Audit Office (NAO) estimates, of the four UK countries, Wales is predicting the lowest increase in expenditure on the NHS per person over the four years to remaining almost constant in cash terms and equating to an average annual fall of 2.3 per cent in real terms. Real terms spending is also expected to fall by, on average, 0.6 per cent per year in Scotland and by 0.4 per cent per year in Northern Ireland, and to remain the same in England per year, between 2010/11 and 2014/15. 2 The most recent King s Fund panel survey of NHS finance directors in England reported that the majority thought that there was a high or very high risk of failure in achieving the 20 billion target beyond Cost containment in the NHS has lead to reductions in the numbers of education and training places being commissioned, to NHS staffing reductions, to reduced investment in skilling up current staff, and to pay freezes. In previous LMRs we have highlighted the history of boom and bust cycles of reduced intakes to training creating staff shortages and the subsequent need to scale up training and rely on high levels of active international recruitment to make good domestic training capacity shortfalls. In last year s LMR we demonstrated that, under most realistic scenarios, there would be a sharp reduction in NHS nursing supply in England over the next ten years as a result of the reductions in intakes to pre-registration and an increase in retirements of the ageing NHS nursing workforce. The reality of a staffing decline over the last two years, which we discuss further in this year s report, is likely to be a continuing trend unless policy makers accept that 1 National Audit Office (2012) Securing the future financial sustainability of the NHS 2 National Audit Office (2012) Healthcare across the UK: A comparison of the NHS in England, Scotland, Wales and Northern Ireland 3 King s Fund (2012) How is the NHS performing? Quarterly monitoring report 3

5 the current reduced intakes to pre-registration nurse education will make a significant contribution to reduced overall supply. There is also an associated need to develop a clearer and more realistic picture of just what level of productivity improvements can be factored into these scenarios on future staffing levels. This concern about reduced supply was echoed earlier this year by the Centre for Workforce Intelligence in its risks and opportunities assessment on acute nursing. It noted that workforce modelling suggested that demand for nurses would soon outstrip supply, with the gap between supply and demand forecast to widen over time 4. It also highlighted that: Although policy changes, demographics and increasing migration suggest that the requirement for adult nurses will continue to increase, feedback from the SHAs has shown that many are decreasing commissions. This poses a potential risk to service delivery... There is a significant risk that this could lead to future shortages. In the 2011 LMR we expressed growing concern that policy makers and planners are currently faced by incomplete and indistinct evidence on the UK nursing workforce at a time when policy choices have to be made which will have major implications for the size, shape and sustainability of the nursing workforce, for patient care, and for individual nurses themselves. Whilst there have been some improvements in the rapidity of publication of NHS workforce data on the last twelve months, there remain major gaps in information on attrition rates, non NHS employment levels, and on levels of use, and reasons for use, of temporary nursing staff in the NHS. In NHS England the continued shortcomings in data have been compounded by uncertainty regarding the shape of NHS workforce planning after the delayed implementation of NHS structural reforms. At the time of writing this report, the new system is not yet fully defined or implemented, and full implementation is running about one year behind the anticipated schedule that was set out at the end of The stated aim is to introduce an employer driven system built around a new national organisation, Health Education England (HEE) and local commissioning bodies, local education and training boards (LETBs). Whilst the new workforce planning and commissioning structure in England remains incomplete, what is clear is that NHS cost containment pressure is impacting on workforce policy in all four UK countries. The NHS is labour intensive, and nursing is numerically one of the largest elements in the workforce, so it is not surprising that there is a policy focus on the workforce. In this year s LMR we update the analysis of the recent decline in NHS nurse staffing levels and in the reduction in domestic training, and we also highlight recent growth in inflow of nurses to the UK from other countries. We give specific focus to the use of temporary nurses in the NHS which has been regarded by some commentators as an indicator of system inefficiency, whilst others are suggesting that flexible staffing can be a source of productivity improvement in an era of fiscal constraint. 4 Centre for Workforce Intelligence (2012) Workforce Risks and Opportunities: Adult Nurse Education Commissioning Risks Summary for

6 The remainder of the LMR is in five further sections: Section 2 profiles the current UK nursing workforce Section 3 provides a detailed focus on international flows of nurses to the UK Section 4 examines trends in the use of temporary nursing staff in the UK Section 5 reports on the supply of new nurses in UK pre-registration nurse education Section 6 concludes with an overview of developments in NHS workforce planning and considers where next? 5

7 2. The current UK nursing workforce In this section we provide an overview of the current UK nursing workforce, with a main focus on NHS employment patterns and trends. 2.1 How many nurses? In March 2012, 669,953 qualified nurses, midwives and health visitors were registered with the Nursing and Midwifery Council (NMC). This is the total pool of potential nurses and midwives available for employment. This was approximately 9,000 higher than the number reported in March Overall reported numbers on the register have fluctuated in recent years, with no clear trend. The NHS is the main employer of nurses in the UK, but nurses also work in a range of other jobs and sectors. Data on nurses employed in the private sector, in nursing homes and other sectors is limited and has reduced in coverage, quality and completeness in recent years. This is occurring at a time when there is growing recognition of the need to capture non-nhs employment trends and to involve non-nhs employers in workforce planning, particularly in England, where the new NHS reforms point to greater involvement of non-nhs providers in employing nurses and in delivering NHS-funded health services. NHS data on the nursing workforce cannot easily be aggregated up to UK level because of differences in definitions and collection methods in the four UK countries, so most trend analysis is best conducted at the level of country within the UK. Table 1 on page 7 uses national NHS workforce data from the four UK countries to assess overall growth in the last ten years. It shows that significant but variable levels of overall nurse staffing growth had been achieved over the period 2001/2011. The data in the table must be interpreted with caution for two main reasons. Firstly, definitions vary in the four countries and across time, which places limits on trend analysis within some countries (notably Scotland) and comparisons between countries. Secondly, measuring staffing change looking at two points in time can give little sense of variation in change across the period under examination, and can also be skewed by the choice of start and finish dates. This latter point will be examined and illustrated in more detail below. 6

8 Table 1: Whole time equivalent and per cent change in the NHS qualified nursing and midwifery workforce, 2001 to 2011, four UK countries (September) %Change England 256, , Scotland 36,425 41, Wales 18,088 21, Northern Ireland 11,502 13, Sources: England: non medical workforce census, excludes bank and agency. The NHS Information Centre. Northern Ireland DHSSPSNI; data is for March; Scotland data - ISD Workforce Statistics; Wales StatsWales. Note: per cent figures are rounded. NOTE: Scotland data for 2011 is not directly comparable with that from 2001 as data collection was re-calibrated using Agenda for Change bands after Data for 2011 is for bands 5-9. This headline percentage increase across the period reflects staffing growth in the earlier part of the last decade, driven by government investment in funding more nurse education places; implementation of policies to improve retention and return, and (mainly in England) a commitment to a policy of active international recruitment up to These policy-led interventions and funding support had in turn been a response to recognised NHS nursing shortages in the late 1990s. Figure 1 on page 9 shows the trends in growth across the ten year period with 2001 as start date, for each of the four UK countries. This figure provides a graphical representation of the relatively rapid growth in the early part of the ten year period, followed by reduced growth rates, and more recently by a flat line or reduction in staffing. For all four UK countries there is a consistent pattern of an arching curve of growth towards the end of the last decade, followed by an actual reported reduction in three of the four UK countries in 2010/2011 (data definitional issues and delays in assimilating some staff during the transition to Agenda for Change in 2007 explain the apparent blip in that year, most notable for Scotland). 7

9 Figure 1: Annual trend in NHS qualified nursing workforce, four UK Countries, (Index 2001=100) Source: data sources as per Table 1 The available comparable national data for the UK countries is at least several months old by the time it is published and as such it may not be an accurate representation of the current situation. This means that policy makers at national level cannot rely on these data to give an up-to-the-minute picture of staffing change. However there have been some recent improvements in the timeliness of data provision by the NHS Information Centre in England and the Information and Statistics Division (ISD) of NHS Scotland, which provide quarterly data at a more rapid cycle of dissemination. NHS Scotland has also asked all NHS Boards to provide workforce projections for 2012/13. The aggregated estimates on staffing change for 2012/2013 show a estimated national increase of WTE (up 0.1 per cent), but an estimated reduction in Nursing and Midwifery of WTE (down 0.6 per cent) (this estimate includes an estimated increase of WTE interns who are supernumerary). The overall reduction is linked to the transfer of WTE nursing and midwifery staff from NHS Highland to Highland Council on 1st April The latest data for England showed a reduction in NHS nurse staffing of 5,780 by headcount and around 3,700 whole-time equivalents. Figure 2 gives more detail on the recent monthly trends in NHS and highlights some seasonal fluctuation, with relative staffing growth in the period September-December, and relative decline in the spring/summer up to August. While there has been an overall decline since 2010, this highlights the risk of assessing staffing change using arbitrarily chosen start and finish months. 5 8

10 Figure 2: NHS qualified nurses, England, Sep 2009-May 2012 (WTE) Source: NHS Information Centre The headline change in the overall number of NHS nurses reflects a continuous process of joiners and leavers new nurses entering the NHS, whilst others leave. Quarterly data on joiners and leavers from the NHS nursing workforce (Figure 3 on page 11) shows some seasonal fluctuation, with the annual number of joiners peaking in the quarter ending in December (perhaps as a result of newly qualified graduates entering the job market), a broader pattern of excess joiners over leavers in the third and fourth quarters and excess leavers in the first and second quarters but gives no conclusive picture of a trend either of net growth or decline in more recent months. Overall, the available data shows a clear tailing off in the rate of NHS nurse staffing growth in the four UK countries, and a more recent decline. 9

11 Figure 3: Quarterly turnover of qualified nursing staff, NHS England, Source: NHS Information Centre A secondary issue, and one that is examined in more detail later in section 4 of this report, is the use of temporary nursing staff (bank and agency). Given the importance to overall workforce planning and policy to have a clear sense of the extent of deployment of temporary nurses this is a growing concern. The absence of consistent data on the level of use of temporary staff makes it extremely difficult to assess their overall contribution, and determine if this is increasing or decreasing. 2.2 Why has staffing growth ended? The supply of new nurses to the NHS and to other employers in the UK comes mainly from pre-registration nurse education in the UK, and, in some time periods, from international sources. Supply from UK pre-registration education has been the major source in recent years, whilst international recruitment made a major contribution in the earlier part of last decade. Pre-registration education is funded by UK governments, and in the early part of the last decade all four UK countries invested in increasing numbers as part of the overall approach to scaling up the nursing workforce in response to recognised staff shortages. This has now been reversed, and as discussed in detail in the next chapter, there is now a year-on-year reduction in intakes to pre-registration education evident across the four UK countries. In essence, UK governments and policy makers determine how many nurses are being trained in the UK through allocation of funding. Every year there are more applicants for 10

12 nurse education in the UK than there are funded training places. Therefore the numbers of nursing students entering UK pre-registration education in the UK and subsequently entering the UK register when they qualify is not a random or uncontrolled event, and is not supply constrained, it is the direct result of funding decisions and subsequent career choice by individuals. There is also an inevitable time lag of three to four years between people entering preregistration nurse education, and these newly-qualified nurses entering the labour market. This emphasises the need to have a clear sense of future supply and demand, locally and nationally, in order to ensure that the commissioning process is cost effective, responsive and flexible in responding to changing trends and demands. It also highlights that if this process is based only on a short term or restricted focus, there is an increased risk of creating future over- or under-supply. As noted in the introduction, there is currently an absence of detail on how the new workforce planning and commissioning process will function in NHS England, but there is an expressed commitment to make it employer led. Experience in the 1990s with locally-driven NHS workforce planning highlighted that there is a considerable risk of creating national undersupply with a locally-led approach to planning, Where there is cost containment pressure in the NHS, local employers often take a narrow, localised view of their future requirements. In addition, the staffing needs of non-nhs employers can be overlooked, as highlighted above. If all these local, narrow views are aggregated up to regional and national level without sufficient checks and balances made to consider wider labour market dynamics, then the end result can be a significant underestimate of future requirements 6. Figure 4 on page 13 shows the annual number of new nurses entering the UK register from education and training in the UK since 1990, and illustrates this point. In 1990/91 there were 18,980 new entrants. The annual number of entrants fell year on year to a low of just over 12,000 in 1997/98, the direct result of funding decisions to reduce the number of preregistration places on offer, despite clear evidence from scenario planning that this number was too low to meet future demand 7. The consequent drop in UK entrants was predictable, given decisions to reduce funding for pre-registration places, and was a major factor contributing to acknowledged nursing shortages later in the decade. 6 Buchan J, Seccombe I and Smith G (1998) Nurses' work: an analysis of the UK nursing labour market. Aldershot: Ashgate Press 7 Buchan J, Seccombe I and Smith G (1998) ibid 11

13 Figure 4: Number of new entrants to the UK nursing register from UK sources: 1990/1 to 2011/12 Source : NMC This led to the self imposed nursing shortage that the UK experienced in the mid/late 1990s, which then had to be addressed by a combination of increased UK training and high volume active international recruitment. Increased funding meant that there was a significant upward trend in intakes after 1997/98, and the increase in pre-registration places led subsequently to more new nurses coming out of pre-registration education in the UK, as can be seen in the figure. The new intake from UK education reached 22,000 in 2008/9, but has subsequently dropped to less than 20,000 per annum in the period since 2009/10, a sign that recent reductions in funding for intakes is beginning to have a knock on effect on numbers of new UK nurses entering the register. 2.3 Summary For the first time in decades there is clear evidence that the overall number of nurses employed in the NHS across the four UK countries has declined. UK governments and policy makers determine how many nurses are being trained in the UK through allocation of funding. There continue to be more applicants for nurse education in the UK than there are funded training places. The numbers of nursing students entering UK pre-registration education in the UK and subsequently entering the UK register is not a random or uncontrolled event, or a reflection of lack of potential recruits, it is the direct result of funding decisions and subsequent career choice by individuals. 12

14 3. An upsurge in international nurses? 3.1 Introduction International recruitment of health professionals can be attractive to policy makers because it enables rapid recruitment without the expense and lead-in time that commissioning more home-based training places requires. In the period between the late 1990s and mid-part of the last decade, organisations in the UK, particularly England, actively recruited nurses from a broad range of countries. In this section, recent international trends and drivers are examined. 3.2 Trends in inflow Whilst there is not precise data on how many international nurses were recruited to, arrived in, and continued to work in the UK, between 1998 and 2006, there were approximately 100,000 new non-uk nurse registrations with the NMC across that period. However, there then followed a period when there was rapid decline in inflow of nurses to the UK from other countries. This change was in part a result of reduced demand in the UK, but also reflected a change in policy stance. Whilst nurses from other EU countries continue to have free access to the UK, under EU Directives, those from other countries have experienced increasing difficulty and costs in attempting to travel to work in the UK. A series of policy changes has made it much more difficult for non-eu nurses to enter the UK. Firstly, in 2005 the NMC instigated a much tougher (and costlier) programme for overseas nurses intending to practise in the UK, the Overseas Nurses Programme (ONP) 8. Secondly, in 2006 the main entry clinical grades in the NHS were removed from the Home Office shortage occupation list. Thirdly, in 2007 the NMC then also raised the English language test requirements. Fourthly, in 2008 the UK immigration policy changed, with the introduction of a points-based work permit system, making international recruitment a more difficult option for employers. More recently, there has been further toughening of immigration policy. In May 2010, the UK government announced their intention to review the immigration system to ensure that net migration reduced between 2010 and 2015 to the levels previously seen in the 1990 s. New immigration rules were brought into force in April 2012 in relation to the approach to granting work permits to new entrants, and approving resident status for non EU nurses currently working in the UK on time limited work permits. The cumulative impact of these self imposed changes is shown in Figure 5 on page 15. This figure uses annual registration data from the NMC, and its precursor, the UKCC. The key indicator is the level of initial admissions to the NMC Register, of nurses and midwives originally trained and registered outside the UK 9. The figure shows the annual number of 8 Nursing and Midwifery Council, Trained outside Europe: Information for nurses and midwives who trained outside of the EU or EEA countries 9 There are limitations in using NMC data to monitor the inflow of nurses to the UK, because it registers intent to work in the UK, rather than the actuality of working. Overseas nurses may be 13

15 new registrants who had come from countries within the EU, and from other international sources. Figure 5: Admissions to the UK nursing register from EU countries and other (non EU) countries 1993/4 to 2011/12 Source: NMC/ Buchan and Seccombe Three key points are evident in examining Figure 5. Firstly, after rapid growth in inflow of nurses to the UK from the late 1990s to the early part of last decade, there was then a marked decline in the overall annual number of new registrations across the period from 2004/2010. Secondly, more recently, from 2010/2012, there has been an upswing in inflow from both EU and non-eu countries. Thirdly, the numbers of nurses from EU countries have increased from a relatively small annual level, to the current situation where they represent the majority of the inflow. The first and second points are emphasised in Figure 6, below which shows the relative size of inflows to the UK register from home-based training and from international sources (EU and non-eu). The international contribution peaked at more than half of all new annual registrants in 2002, then declined rapidly until 2010, when it represented only one in ten of new registrants. However, since 2010, the international contribution has grown, reaching about 4,000 new registrants in 2011/12, double the number of two years earlier, and representing about 18 per cent registrants that year. Romania, Portugal, Spain and Ireland were the main EU source countries, whilst India and the Philippines were the main non-eu sources. Whilst it is too early to be clear if this represents the beginning of an upsurge in registered, but not move to the UK, or they may move to the UK but not take up employment in nursing. 14

16 international inflow, it is apparent that the decline up to 2010 has now been reversed, in overall terms. Figure 6: International and UK sources as a percentage of total new admissions to the UK nursing register, 1989/90 to 2011/12 Source: NMC/ Buchan and Seccombe It is also apparent that the increase in inflow has occurred in both EU and non EU nurses, but that the former now comprise the majority. The policy relevance of this last point is that EU nurses have free mobility to enter the UK when they wish. They are not subject to immigration controls, and from a UK policy and planning perspective are an unmanaged inflow; they cannot be directed, and the length of their stay in the UK cannot be determined. Given ease of movements and relatively cheap travel costs between the UK and EU countries, it is also likely that there will have been an increasing number of commuting EU nurses, who travel frequently between the UK and other countries in the EU on a regular basis 10. These changing dynamics highlight that international flows will be less open to management by UK policy makers and regulators, with the majority inflow from the EU, and length of stay in the UK, being determined primarily by individual choice and circumstances of the nurse. 10 Wismar M, Maier C, Glinos I, Dussault G and Figueras J (2011) Health Professional Mobility and Health Systems: Evidence from 17 European countries. WHO European Observatory, Brussels 15

17 The growth in significance of inflow from the EU has been triggered by two events. Firstly, the entry of accession countries to the EU in the mid-part of the last decade enabled nurses in these countries to move freely within the EU, and this led to an initial growth in nurse entrants to the UK from new EU states such as Poland and Romania. Secondly, and more recently, there has been a marked increase in nurses registering in the UK from EU countries experiencing extreme labour market problems in the eurozone economic crisis. Nurses from countries such as Portugal and Spain have not been traditional entrants to the UK, but there has been a sudden marked increase from these countries (see Figure 7 below). Figure 7: New admissions to UK register from selected EU countries 2006/7 to 2011/12 Source: NMC/ Buchan and Seccombe Figure 7 shows new admission from selected EU countries since Different patterns of inflow from different countries are clear. The number of nurses admitted to the UK register from Portugal, one of the crisis countries, has grown from 20 in 2006/7 to more than 550 in 2011/12. Whilst some of this flow will represent a push from poor employment opportunities in Portugal, there have also been media reports of active recruitment of Portuguese nurses by NHS organisations in , 12 and Conceição C, Ribeiro J, Pereira J and Dussault G (2011) Portugal: Mobility of Health Professionals, Associação para o Desenvolvimento da Medicina Tropical, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. 12 Howie M (2011) Spanish and Portuguese nurses fill the gaps in the NHS. The Guardian, 20 December 13 Williams D (2012) Trust looks to Portugal for new nursing recruits. Nursing Times, 26 July 16

18 Another crisis country, Ireland, has been a traditional source of nurse recruits for the UK, but by the middle of the last decade, the Irish economy and health service were expanding, and Ireland became one of the most active recruiters of nurses, whilst also retaining most that it trained. Ireland became one of the most active recruiters of nurses in the English speaking world 14. In 2006/7 fewer than 100 nurses from Ireland were registered in the UK; three years later that figure had increased to more than 400 as the crisis hit the Irish health system and job opportunities for nurses reduced drastically. Poland, one of the accession states, initially was the source of several hundred registrants per year in the UK, but in more recent years the number of registrants has dropped: this may be a reflection of the fact that the Polish economy has fared relatively well in the economic crisis. The potential contribution of international recruitment of nurses to the UK can be shown by using a NHS nursing workforce model developed in 2011, and using it to assess the implications of projecting forward historically low and high levels of inflow of nurses to the UK 15. Figure 8 below shows the trend in NHS nursing supply if historically current [c 2010] or historically high [c 2002] annual international inflows were maintained up to Figure 8: Total supply of NHS nurses under "low"(current) and "high" scenarios of inflow of international nurses, Source: Buchan and Seccombe The outputs from this modelling with current and high international flows being projected, and all other inflows and outflows being held constant highlights just how significant can be the impact of international recruitment on the total stock of the NHS nursing workforce. The end result is 33,750 fewer NHS nurses in 2021/2 than in 2011 under the low international 14 Humphries N, Brugha R and McGee H (2009) Retaining Migrant Nurses in Ireland II. Nurse Migration Project Policy Brief 3. Dublin: Royal College of Surgeons in Ireland 15 Buchan J, Seccombe I (2011) A decisive decade: The 2011 UK nursing labour market review. Royal College of Nursing: London data/assets/pdf_file/0006/405483/lmr2011_final.pdf 17

19 inflow scenario, or 47,700 more nurses if international inflow is projected at the historically high level: a gap of more than 80, Outflow of Nurses from the UK International flow of nurses is two way. Recent UK nursing journals carry advertisements from a range of other countries aiming to recruit UK nurses, and there have been specific attempts by Australian recruiters to deliberately target areas of the UK, where NHS job cuts and recruitment freezes have been announced. Some estimates of the outflow of nurses from the UK can be determined using data held by the NMC on verifications reported to other countries. Whenever a UK registered nurse applies for registration in another country, that country s registration body should contact the NMC for verification of the nurse s details 16. Overall trends in this measure of outflow are shown in Figure 9. The annual number of verifications issued increased steadily across the period from 2001/2 to 2008/9, then dropped, and appears to have grown in 2011/12. In comparison to inflow as measured by new registrations, it is clear from the figure that the UK has moved from a situation of likely net inflow in the first half of the last decade to a position of net outflow in recent years. 16 The NMC data indicates an intention to nurse in other countries, it does not necessarily record an actual geographical move. There will also be some double counting when a nurse applies to move to more than one country, and some of the outflow will be of foreign nationals who, having undertaken pre- or post-registration nurse education in the UK, return home. 18

20 Figure 9: Inflow and outflow of nurses from the UK, 1993 to 2012 Source: NMC/Buchan and Seccombe A more detailed examination of verifications issued in the last three years, in Figure 10 shows that the vast majority are issued for just four English speaking developed countries Australia, Canada, New Zealand and the USA. Australia alone accounts for half or more of all verifications issued in 2011/12 this amounted to 4,197 verifications. Whilst some of these will have been triggered by Australian nurses who have been working in the UK who are planning to return home, this represents a significant potential outflow 17. This data also highlights significant imbalances in flows between countries. The UK is losing nurses to Anglophone developed countries, but is mainly recruiting from EU crisis countries and from Anglophone developing countries. For example, in the same year that there were more than 4000 verifications issued for nurses considering moving from the UK to Australia, there were only 201 new registrations of Australian-trained nurses in the UK. 17 Australia has recently moved from state level to national registration of nurses; it is not clear what effect, if any, this will have had on trends in NMC verification data. 19

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